Process an Invoice (C-Lines)

Completed by*

Agency Name*

Enter the agency name, FYI this does not have an affect on automatic routing

Agency Info:

Today Date*

Date

Invoice being issued for*

Enter the Agency Name (DBA)*

Enter the Agency Phone Number*

Agency Street Address

Agency City Address

Agency State Address

Agency Zip Address

Enter the Agency Fax Number*

Enter the Agency E-mail*

Client Info:

Is the Insured a legal entity such as a LLC or Corporation or are they Individual people/sole proprietor*

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the Business entity. This must match 100% exactly as it appears on the policy*

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

How many named insured will there be in the policy, therefore showing on the Invoice. (Must match the Policy)*

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the 1st Named Insured*

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

What is the name of the 2nd Named Insured*

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

What is the name of the 3rd Named Insured*

IMPORTANT: This must match 100% exactly as it appears on the policy declarations

Does the named insured use a DBA*

Note: This DBA would be how the business is advertised to the public unless they use the entity name only

What is the name of the DBA.*

IMPORTANT: Make sure to enter the DBA name as it appears on all publications

mapping-DBA name*

Will the DBA need to appear on COI*

Note: This DBA would be how the business is advertised to the public unless they use the entity name only

Named Insured Address*

Policy Information:

How many policies are we going to invoice for*

What is the line of Business for the 1st policy*

What is the policy or quote number for the 1st policy*

What is the cost of the 1st policy that includes premium + taxes + BK Fee*